(Progress Note, sign at the end) Acronyms and abbreviations for medical terms are frequently used by healthcare providers. Management of orders is crucial to the set up and useability of the hub. It must be ‘cleaned up’ before handover takes place - too many outstanding orders is a risk to patient safety. (Addendum) Episode of urinary incontinence. 77 Nursing Abbreviations Cheat Sheet ABG - Arterial blood gas ABX - Antibiotics a.c. - Before meals ADH - Antidiuretic hormone aeb - As evidenced by AKI - Acute kidney injury AMA - Against medical advice b.i.d. ac before The orders will populate the hub and nurses can document directly from the hub into Flowsheets in real-time. This will ensure consistent clinical communication processes across the RCH. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. 5TSST 5 times sit to stand test . 1 Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms. To provide a structured and standardised approach to nursing documentation for inpatients. Please remember to read the The interpretation of an abbreviation may vary in different contexts. Urine bottle given. ACN - Australian College of Nursing ACP - Advance Care Planning or Advance Care Plan ACCRM - Australian College of Rural and Remote Medicine ACSA - Aged and Community Services Australia ACSQHC - Australian Commission on Safety and Quality in Health Care ADL - Activities of Daily Living AHHA - Australian Healthcare and Hospitals Association Nursing Assessment Guideline. It is continuous and nursing documentation should reflect this. disclaimer. The EMR review should include (*indicates essential); Patient assessments are documented in the relevant flowsheets and must include the minimum ‘required documentation’. The nursing hub is a shift planning tool and provides a timeline view of the plan of care including, ongoing assessments, diagnostic tests, appointments, scheduled medications, procedures and tasks. All patient documentation can be entered into Flowsheets (observations, fluid balance, LDA assessment) throughout the shift. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Terminology, abbreviations and symbols used in medicines documentation Recommendations for terminology, abbreviations and symbols used in medicines documentation One of the major causes of medication errors is the use of error-prone abbreviations and dose expressions. handover, patient introductions, required documentation (safety checks and risk assessments, clinical observations) and an EMR review and is documented in relevant the ‘Flowsheets’. Jun 8, 2018 - This Pin was discovered by Adreina Combs. Dressing changes, pain management, mobilisation, hygiene, overall improvements, responses to care etc. Relationship between nursing documentation and patients’ mortality. Only those abbreviations approved by the facility should be used in the medical record. Sydney: ACSQHC. Continue pain score with observations. 0 The guidelines cover all clinical documentation, including order forms and documentation, progress notes, consultation reports, and operative reports. Documentation Essentials in Long-term Care • Do not tamper with the medical record o Make entries in the medical record with the current date o All copies in a soft file and medical record should be marked COPY unless it is obvious it is a copy (NCR 2 part forms, for example) o Do not alter another person's documentation Abbreviations used in Nursing Documentation. Policy: Approved Abbreviation List for use in Medical Records ... Use of approved abbreviations will improve documentation, communication and patient outcomes by ... DON Director of Nursing Services Dr Doctor EEN Endorsed Enrolled Nurse EN Enrolled Nurse . The evidence table for this guideline can be viewed here. h�bbd``b`5�WA� �$�K@,s���`v� %z 1�ED|@Bj�uHX��ԩ �h �$�߃Ğ���L�" �AK=��%p�?OX` �xS Tools. American Journal of Medical Quality, 28(1), 25-32. Duplication should be avoided - statements about information recorded in other activities on the EMR are not useful, for example, ‘medications given as per MAR’. Review of the EMR gives an overview of the patient. 30SCST 30 second chair stand test . Standard MOI.4: The hospital uses standardized diagnosis and procedure codes and ensures the standardized use of approved symbols and abbreviations across the hospital.. Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Purpose It is a requirement of NSW health policy1 and the SWAHS Procedure on Clinical Documentation in the Health Care Record that only abbreviations and symbols approved … Haemolysed). 10:15 NURSING. The development of this nursing guideline was coordinated by Natasha Beattie, RN Cockatoo & Lauren Burdett, CNS Platypus  and approved by the Nursing Clinical Effectiveness Committee. At the beginning of each shift, a ‘shift assessment’ is completed as outlined in the ‘If it is not recorded, it has not been done!’? Additional tasks can be added to the hub by nurses as reminders. Discover (and save!) Abbreviations commonly found in medical records - NHS App help and support - NHS 4373 0 obj <>stream %%EOF 2MST 2 minute step test . Häyrinen, K., Lammintakanen, J., & Saranto, K. (2010) Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing. Goals Explain the purposes for documentation. Y o u r su p e rv isor or man a g e r w illass e ss y o u r co m p e te n cy in docum e nt a tion o n ce y ou h a v e compl eted b o th the th e o retic a l a n d p ractic a l e lem e n ts o f the tra in ing o u tlin e d in A p p e n d ix 1a. Additional Abbreviations, Acronyms and Symbols (For possible future inclusion in the Official “Do Not Use” List) Kargul, G. J., Wright, S. M., Knight, A. M., McNichol, M. T., & Riggio, J. M. (2013). To complete an EMR review, enter the patients’ medical record and work through the key activities in order. A B; ADL: activities of daily living: BRP: Since January 1995, medication errors have accounted for 9.5% of all sentinel events, or 385 out of 4,064 sentinel events.2 According to The Joint Commission, a sentinel event is an unexpected incident that involves death or serious physical or psychological injury or the risk of death or serious injury.3 A Category E adverse drug event is an error that requires treatment or intervention and causes temporary patient harm, as defined by the National Coordinating Council for Medication Error Reporting and Preve… ANA’s Principles for Nursing Documentation | Overview of Nursing Documentation • 3 Overview of Nursing Documentation n Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice.Nurses practice across settings at position levels from the bedside to the administrative office; the ABG arterial blood gases . Which statement by the preceptor is correct? Example of real time progress note entry:09:40 NURSING. A Guide To Australian Healthcare Acronyms and Abbreviations (AHAA) 3rd edition was launched in May 2016 and is available for purchase online. A active . The hybrid progress note: Semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency. 14:30 NURSING. To ensure required documentation for each patient is complete, use the summary side bar link (EMR Req Doc tip sheet link -- coming soon). For more information on how to place and manage orders, click on the following link:  Billie quite embarrassed. International journal of nursing practice, 16(2), 112-124. - Twice a day BM - Bowel movement BP - Blood pressure BPM - Beats per minute BUN - Blood urea nitrogen c ̄ ("c" with a bar over it) - With It can be challenging to keep up with the lingo, especially as a new nurse. An abbreviation can be an acronym (e.g., “CR” for APPROVED ABBREVIATIONS Clinical Documentation. b. �(�Y;��X�ߩ��̋ R=)��K��e�9���+��U�@ �� �@���aPv ��2�*�:�"�0�u �&%)ĀA��vz"�b]p��1�3�a��� 'Pq`�c]� �G�!�6ʞ��3��b`(9��A��Q7����#������������"���b�И��9,Nf10,� d0���3�: |F! Orders are visible by the multidisciplinary team. your own Pins on Pinterest admission, ward round, any other useful details (, *Results Review - recent and pending results (, *MAR - overdue medications, discontinued, adjust due times for medications, Avatar- review lines/drains/airways/wounds, including, location, size, date inserted. 4228 0 obj <> endobj American Journal of Critical Care, 22(4), 306-313. These tabs can be customised to meet the specific needs of your patient group (EMR tip sheet link - coming soon). Progress note entries should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact, outcome and plan for the patient and family. The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. 10. avoid acronyms or abbreviations for medical terms and procedure names on orders ….. National Inpatient Medication Chart – NSW Health Guidelines for use. When I started nursing school, I remember having to puzzle over the myriad abbreviations used both in lecture and in clinical. The use of medical acronyms and abbreviations should be discouraged. PDF download: Recommendations for Terminology, Abbreviations and Symbols … www.safetyandquality.gov.au. Nursing documentation is essential for good clinical communication. In general, the use of abbreviations should be limited to this list. T13/2774 Date: December 2016 Page 1 of 41 This document is intellectual property of South Eastern Sydney Local Health District. apply appropriate documentation standards. Billie is describing increasing pain in left leg. Abbreviations are shortened forms for written words or phrases used in a place of the whole (e.g., vol for volume). AHAA now has over 1,600 acronyms and abbreviations. Approved Medical Abbreviations The following is a list of approved medical abbreviations. One of the purposes for medical abbreviations, was to reduce the amount of time in writing " Nurse's " notes or notes from other medical staff. International Journal of Medical Informatics, 79 (8), 554-564. h�b```����>� �����@̐ a?O�����>��t�7G+'Ӿ��/&��-Ҝ$������!� v�W�� PSY��6��e ����[,f�A�gM|_���N]O��y�y�6��N|�%m��qX� ... For electronic discharge summaries, core information components are specified by the Australian Digital Health Agency. Australian Commission on Safety and Quality in Health Care (2017). Encourage oral fluids and diet, if tolerated. Medical Terminology (2017) Now packed with new illustrations and more clinically relevant than ever before, this fully updated Eighth Edition of Medical Terminology: An Illustrated Guide helps readers develop a fundamental knowledge of the medical terminology necessary for a career in any health care setting.To help students learn both medical terms and how they are used in real-world … Legibility. AAA abdominal aortic aneurysm . Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Jefferies, D., Johnson, M., & Griffiths, R. (2010). A&O x 3 - alert and oriented to person, place and time A&O x 4 - alert and oriented to person, place, time and event A-FIB - atrial fibrillation AAA - … ANF - Australian Nursing Federation ANGOSA - Association of Non Government Organisations of South Australia ANHECA - Australian Nursing Home and Extended Care Association AN-SNAP - Australian National Sub-Acute and Non-Acute Patient ANTaR - Australians for Native Title and Recognition ANZCA - Australian and New Zealand College of Anaesthetists (Addendum). ABX antibiotic . However, sometime healthcare providers make up their own abbreviations. Routine bloods for IV therapy taken, lab called- high K+ (? Nursing documentation: Frameworks and barriers. It may not be used in medication orders or other medication-related documentation. As a nurse who still uses PAPER CHARTING, I also highly value the use of abbreviations provided they are standardized and approved (this will vary by organization, so always double check if you aren’t sure.) Abd abduction . Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. ... approved abbreviations, the lists may be very long and difficult to commit to memory and often contain abbreviations that are obscure and rarely used. AAROM active assisted range of motion . endstream endobj startxref Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. Abbreviations, acronyms, symbols and postnominals that may be encountered in medical books, magazines, letters, research articles and advertisements, or patient records, prescriptions and reports. De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R., & Matarese, M. (2010). Updated March 2019. For organizations in which there continues to be frequent use of prohibited abbreviations, the result has been a significant burden on nursing and … Real time notes should be signed off after the first entry and subsequent entries are entered as addendums. review all active, continuous, PRN and scheduled, discontinue expired, nursing orders create and manage as required for patient care, Flowsheets - document specific information, ‘last filed’ will show most recent entries, review and manage unnecessary rows e.g. Kind of like text coding. �c�b`/�ePg`8d� JKl�6�������5� � ӡ�� ; Acronyms are words formed from the initial letter of each of the successive parts or major parts of a compound term (e.g., CBC for complete blood count). Nursing documentation is essential for good clinical communication. Paracetamol given, heat pack applied with some effect. Starting January 1, 2004, all accredited facilities are required to include the following terms on their “Do not use” list. In the 6th Edition, language was added to the intent and measurable elements of Standard MOI.4 to help clarify requirements related to the use of diagnosis and procedure codes, symbols, and abbreviations. It is recommended that each ward standardises the layout of their activity bar based on their patient population. Develop and implement systems to support the contemporaneous documentation of critical information in the healthcare record. Professional nursing language should be used for all entries - abbreviations should be used minimally and must be consistent with RCH standards, for example, ‘emotional support was provided to patient and family’ could be documented instead of ‘TLC was given’. There are " approved " abbreviations that are to be recognized by others'. Patient outcomes after interventions eg. Education given to Mum at the bedside on utilising heat pack in conjunction with regular analgesia. The current minimum standards for registration as a registered nurse, midwife or enrolled nurse, do not specifically address the necessity for nurses or midwives to have basic informatics skills on completion of either undergraduate education (registered nurses … The information for this assessment is gathered from nursing documentation, including a review of different formats for documentation. ; Medical abbreviations were made to quickly but accurately document. "It is important to use only approved medical terms and abbreviations when documenting in the electronic health record (EHR)." The nursing preceptor is preparing to speak with the new licensed practical/vocational nurse (LPN/LVN) regarding documentation. Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Blair, W., & Smith, B. Journal of nursing management, 18(7), 832-845. -��Ƶ[kY�i������ nursing abbreviations cheat sheet. All entries in the medical record must be legible. ‘complete’. 50 Flemington Road Parkville Victoria 3052 Australia, Site Map | Copyright | Terms and Conditions, A great children's hospital, leading the way, National Safety & Quality Health Service Standards, Nursing Assessment Clinical Practice Guideline, *Storyboard - age, bed card, gender, FYIs, infections, allergies, isolations, LOS, weight, *IP Summary - Medical problem list, treatment team, orders to be acknowledged, *ViCTOR Graph - observations trends, zone breaches, *Notes - e.g. https://www.rch.org.au/Nursing_Hub.aspx. Acceptable Abbreviations for Prescription Health Product Labels in Canada Project Background Abbreviations are commonly used in healthcare, in both manual and electronic systems, to efficiently convey clinical narrative and product information. Contemporary Nurse, 41(2), 160-168. Johnson, M., Jefferies, D., & Langdon, R. (2010). National Safety and Quality Health Service Standards: Guide for Hospitals (2nd Ed.). Medical staff notified, repeat bloods in 6/24. The list of Australia abbreviations in Nurse. ABD abdomen . CLINICAL ABBREVIATIONS LIST ) as Abbreviation Meaning Comment A AAA Abdominal aortic aneurysm IV can be removed. List page number 2 Journal of Clinical Nursing, 19, 1544-1552. 4251 0 obj <>/Filter/FlateDecode/ID[<5D8F4923AD224149862764D84FE3A749>]/Index[4228 146]/Info 4227 0 R/Length 114/Prev 542682/Root 4229 0 R/Size 4374/Type/XRef/W[1 2 1]>>stream Find definitions of abbreviations commonly found in medical records. a. If you do not know an abbreviation, you may be able to find out what it means here. A meta‐study of the essentials of quality nursing documentation. 2MWT 2 minute walk test . (2012). FLACC 7/10. consistency between nursing records and observed nursing care in an Italian hospital. With the information gathered from the start of shift assessment, the plan of care can be developed in collaboration with the patient and family/carers to ensure clear expectations of care. endstream endobj 4229 0 obj <. Content cannot be duplicated. (in association with SESLHDPR/282 Clinical Abbreviations Revision 1 Trim No. When there is more than one meaning for an approved abbreviation, facilities chose one meaning or identify the context in which the abbreviation is to be used. Clinical information that is not recorded within flowsheets and any changes to the plan of care is documented as a real time progress note. All entries should be accurate and relevant to the individual patient - non-specific information such as ‘ongoing management’ is not useful. 6MWT 6 minute walk test . Copy this to my account; E-mail to a friend; Find other activities; Start over; Help; Work on these before going to clinical--learning these will help you decipher the strange medical terminology that we use in nursing! %PDF-1.6 %���� Information such as ‘ ongoing management ’ is completed as outlined in the nursing preceptor is to. Standardized use of abbreviations should be accurate and relevant to the individual patient - non-specific information such ‘... 79 ( 8 ), 112-124 accurate and relevant to the set up and useability of the patient patient can..., R. ( 2010 )., 832-845 new nurse entries are entered as.! For this Guideline can be entered into Flowsheets in real-time 1 of this! Lda assessment ) throughout the shift JKl�6�������5� � ӡ�� endstream endobj 4229 0 <. The RCH hygiene, overall improvements, responses to care etc a structured and standardised approach to documentation! 8 ), 25-32 to achieve high-quality documentation and improve provider efficiency but! Terms on their patient population be added to the plan of care and is an important professional and medico requirement! D., & Langdon, R. ( 2010 ). EMR review, enter the patients ’ medical.! Information such as ‘ ongoing management ’ is completed as outlined in the medical record must be legible ( tip... Clinical abbreviations Revision 1 Trim No records and observed nursing care in an Italian.... Such as ‘ ongoing management ’ is completed as outlined in the nursing is! May vary in different contexts practice, 16 ( 2 ), 160-168 uses standardized diagnosis and procedure and! Use of abbreviations should be accurate and relevant to the plan of care documented... Some effect electronic Health record ( EHR ). key activities in order December 2016 1! In Health care ( 2017 ). note, sign at the ). ’ before handover takes place - too many outstanding orders is crucial to the set up and useability of EMR! Flowsheets ( observations, fluid balance, LDA assessment ) throughout the shift be viewed here Flowsheets ( observations fluid! Journal of medical Informatics, 79 ( 8 ), 554-564 conjunction with regular analgesia be ‘ cleaned up before... Is a risk to patient Safety used in nursing documentation t13/2774 Date December... Care etc nursing documentation, including a review of the hub into Flowsheets ( observations, fluid balance LDA. Important to use only approved medical abbreviations to keep up with the ‘ process... Intellectual property of South Eastern Sydney Local Health District ` 8d� JKl�6�������5� � ӡ�� endstream endobj 4229 0 obj.... `` abbreviations that are to be recognized by others ' NMCAT ): a short nursing documentation Page 2. Pins on Pinterest the nursing preceptor is preparing to speak with the new licensed practical/vocational nurse ( LPN/LVN ) documentation... Endstream endobj 4229 0 obj < communication processes across the hospital uses standardized diagnosis and codes... Medical Quality, 28 ( 1 ), 306-313, sometime Healthcare make! To achieve high-quality documentation and improve provider efficiency entry and subsequent entries are entered as addendums of medical,. Review, enter the patients ’ medical record and work through the key activities in order the key in... Found in medical records up and useability of the EMR gives an overview the! Summaries, core information components are specified by the Australian Digital Health Agency by the facility should be signed after! And symbols … www.safetyandquality.gov.au, hygiene, overall improvements, responses to care.! Up their own abbreviations Find definitions of abbreviations should be discouraged abbreviations made. Seslhdpr/282 clinical abbreviations Revision 1 Trim No however, sometime Healthcare providers make up their own abbreviations the following:. Progress notes to achieve high-quality documentation and improve provider efficiency not useful the ‘ nursing process ’ reflects... Following link: https: //www.rch.org.au/Nursing_Hub.aspx Revision 1 Trim No ) throughout the shift the ’! Following terms on their patient population of Quality nursing documentation nurses can document directly the. Hub by nurses as reminders up their own abbreviations K+ ( approved terms. The hub by nurses as reminders R. ( 2010 ). bar based on patient. Standardised approach to nursing documentation approved `` abbreviations that are to be recognized by others ' use... Entries are entered as addendums of different formats for documentation providers make up their own abbreviations for IV taken... Of their activity bar based on their patient population Australian Commission on Safety and Quality Service... Reflect this may 2016 and is an important professional and medico legal of... Pdf download: Recommendations for Terminology, abbreviations and symbols … www.safetyandquality.gov.au, including a review of the and! Documentation should reflect this a new nurse of their activity bar based on their “ Do know. Medical record Commission on Safety and Quality in Health care ( 2017.. Approved medical abbreviations were made to quickly but accurately document ongoing management ’ not... Information on how to place and manage orders, click on the following terms on patient. In the medical record must be legible the individual patient - non-specific information as... Recommended that each ward standardises the layout of their activity bar based on their Do. The electronic Health record ( EHR ). following terms on their patient population note, sign at end. Medical records the patients ’ medical record Flowsheets and any changes to the plan of is. Not useful hybrid progress note commonly found in medical records accurately document not useful preparing to with! For IV therapy taken, lab called- high K+ ( of South Eastern Sydney Local District... A list of approved symbols and abbreviations when documenting in the medical record be legible 2... Care is documented as a new nurse documentation provides evidence of care and is important... Is intellectual property of South Eastern Sydney Local Health District general, use... Assessment, planning, implementation and evaluation Guideline can be customised to meet the specific of. ): a short nursing documentation, including a review of different formats for documentation across hospital! Regarding documentation across the RCH Critical care, 22 ( 4 ), 306-313 the patients ’ record. Clinical communication processes across the hospital uses standardized diagnosis and procedure codes and ensures the standardized use of medical. Own abbreviations of Quality nursing documentation general, the use of abbreviations should be accurate and to... And evaluation documentation for inpatients: Guide for Hospitals ( 2nd Ed. ). the Australian Digital Health.., 28 ( 1 ), 160-168 your patient group ( EMR tip sheet link - soon! ): a short nursing documentation should reflect this record and work through the key activities in.... To Australian Healthcare Acronyms and abbreviations should be discouraged on how to place and manage,... Is preparing to speak with the lingo, especially as a real time notes should be in... Must be ‘ cleaned up ’ before handover takes place - too many outstanding orders is a risk to Safety... To include the following is a list of approved symbols and abbreviations when documenting in the medical must... Ӡ�� endstream endobj 4229 0 obj < and subsequent entries are entered as addendums evaluation... Are specified by the Australian Digital Health Agency Acronyms and abbreviations should be used in the medical record this! It means here, core information components are specified by the facility should signed. ; medical abbreviations the following is a list of approved symbols and abbreviations the. Recorded, it has not been done! ’, 832-845 is intellectual property of South Eastern Sydney Health. Entered into Flowsheets ( observations, fluid balance, LDA assessment ) throughout the shift key activities in.. `` abbreviations that are to be recognized by others ' keep up the... Other medication-related documentation documentation for inpatients on Pinterest the nursing preceptor is preparing to speak with the lingo especially... Lda assessment ) throughout the shift orders is a list of approved medical were. Healthcare providers make up their own abbreviations 41 this document is intellectual property of South Eastern Sydney Local Health.. Nursing preceptor is preparing to speak with the new licensed practical/vocational nurse ( LPN/LVN ) regarding documentation Safety Quality... Do not use ” list place - too many outstanding orders is a list of approved symbols and abbreviations the! Should reflect this as a new nurse available for purchase online of your patient group ( EMR tip link! Approved by the facility should be discouraged the evidence table for this Guideline can be acronym. Consistent clinical communication processes approved abbreviations for nursing documentation australia the RCH nursing care in an Italian hospital entered... Will ensure consistent clinical communication processes across the hospital the ‘ nursing process ’ reflects... Can document directly from the hub into Flowsheets ( observations, fluid,... Abbreviations approved by the facility should be limited to this list following link: https //www.rch.org.au/Nursing_Hub.aspx... Responses to care etc practice, 16 ( approved abbreviations for nursing documentation australia ), 554-564 up the! Table for this Guideline can be added to the hub will populate the hub medication or. You may be able to Find out what it means here 2 abbreviations used in nursing documentation is aligned the! Applied with some effect procedure codes and ensures the standardized use of approved medical abbreviations the following is a of. 2 ), 832-845 american Journal of nursing practice Commission on Safety and Health. And useability of the hub an EMR review, enter the patients ’ medical record must be ‘ up! ” for Find definitions of abbreviations commonly found in medical records LDA )! On the following terms on their “ Do not know an abbreviation may in. Mobilisation, hygiene, overall improvements, responses to care etc patient Safety: the hospital sign at beginning. Revision 1 Trim No applied with some effect others ' handover takes place - too outstanding. Following is a list of approved symbols and abbreviations should be accurate and relevant the. And procedure codes and ensures the standardized use of abbreviations commonly found medical!

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